Culture, Health & Sexuality
An International Journal for Research, Intervention and Care
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tchs20
Pathways of change: qualitative evaluations of
intimate partner violence prevention programmes
in Ghana, Rwanda, South Africa and Tajikistan
Erin Stern, Samantha Willan, Andrew Gibbs, Henri Myrttinen, Laura
Washington, Yandisa Sikweyiya, Adolphina Addo-Lartey, Subhiya
Mastonshoeva & Rachel Jewkes
To cite this article: Erin Stern, Samantha Willan, Andrew Gibbs, Henri Myrttinen, Laura
Washington, Yandisa Sikweyiya, Adolphina Addo-Lartey, Subhiya Mastonshoeva & Rachel
Jewkes (2021) Pathways of change: qualitative evaluations of intimate partner violence prevention
programmes in Ghana, Rwanda, South Africa and Tajikistan, Culture, Health & Sexuality, 23:12,
1700-1716, DOI: 10.1080/13691058.2020.1801843
To link to this article:  https://doi.org/10.1080/13691058.2020.1801843
© 2020 The Author(s). Published by Informa Published online: 08 Sep 2020.
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CULTURE, HEALTH & SEXUALITY
2021, VOL. 23, NO. 12, 1700–1716
https://doi.org/10.1080/13691058.2020.1801843
Pathways of change: qualitative evaluations of intimate
partner violence prevention programmes in Ghana,
Rwanda, South Africa and Tajikistan
Erin Sterna , Samantha Willana , Andrew Gibbsa , Henri Myrttinenb
 ,
Laura Washingtonc, Yandisa Sikweyiyaa, Adolphina Addo-Larteyd,
Subhiya Mastonshoevab and Rachel Jewkesa
aGender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa;
bInternational Alert, London, UK; cProject Empower, Durban, South Africa; dSchool of Public Health,
University of Ghana, Accra, Ghana
ABSTRACT ARTICLE HISTORY
A critical component of evaluations of the effectiveness of intim- Received 13 December 2019
ate partner violence prevention programmes involves understand- Accepted 22 July 2020
ing pathways of change among individuals who participate in
such programmes, and the intervention or contextual elements KEYWORDS
that support or hinder these. This paper draws on qualitative eval- Intimate partner violence;
uations of four intimate partner violence prevention programmes gender; intervention;principles for success
in Ghana, Rwanda, South Africa and Tajikistan conducted as part
of the What Works to Prevent Violence against Women and Girls
Programme. Using a comparative case study approach, a second-
ary analysis was applied to thematically analysed data to explore
how and why men and women change in response to different
types of programmes across diverse contexts. Similar pathways of
change were identified including the value of learning and apply-
ing relationship skills to support equitable, non-violent relation-
ships; the importance of participatory approaches to challenge
harmful gender norms and allow for group rapport; and the inte-
gration of economic empowerment activities to reduce drivers of
intimate partner violence and conflict, and promote participants’
self-confidence and status. These findings provide insights regard-
ing intervention design and implementation factors pertinent to
bring about changes in intimate partner violence.
Introduction
The proliferation of intimate partner violence prevention programme evaluations has gener-
ated significant insights into what works to prevent intimate partner violence. A recent
review summarised the core elements of more successful interventions as including: a strong
contextually rooted theory of change; the use of participatory, group learning methods;
C
ONTACT Erin Stern Erin.a.stern@gmail.com; erin.stern@lshtm.ac.ukCurrent affiliation: Gender Associations Consulting, Berlin, Germany.

 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in
any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
CULTURE, HEALTH & SEXUALITY 1701
working with men, women and their families collectively; focusing on multiple drivers of vio-
lence; and rigorous implementation (Jewkes et al. 2019). However, we have much less under-
standing of how interventions work, the pathways to change among individuals who
participate in such programmes and the intervention or contextual elements that support or
hinder this. Analysing pathways of change is particularly important given the complexities of
shifting harmful gender norms and acceptability of the use of violence. Moreover, effective
intimate partner violence prevention interventions are typically quite complex and often
work at multiple levels, or with different interacting components (Davis et al. 2019).
Participants’ interaction with programmes, including the negotiations and struggles that
lead to change (Sullivan 2004), are not well understood.
The UK Department for International Development (DFID)-funded What Works to
Prevent Violence against Women and Girls (VAWG) Programme has generated evidence
around the effectiveness of intimate partner violence prevention programmes from 13
countries in Asia and Africa. This paper explores pathways of change through qualitative
evaluations of four of the studies included in the portfolio. We included studies with
quantitative evidence of reducing intimate partner violence and/or domestic violence for
some participants, with ample qualitative data available, targeting heterosexual adults as
the primary beneficiaries. The included studies cover a diversity of approaches: commu-
nity mobilisation (Rwanda, Ghana), livelihood strengthening and gender-transformative
training (South Africa, Tajikistan, Rwanda) and working with couples (Rwanda).
Using a comparative case study approach (Goodrick 2014), we explore how and why men
and women changed in response to diverse programmes across different contexts, and the
intervention and contextual enablers and/or barriers underlying this. A comparative case
study approach involves the analysis and synthesis of similarities, differences and pathways
across two or more cases that share a common focus or goal (Goodrick 2014), which in doing
so offers a more nuanced consideration of processes and context (Bartlett and Vavrus 2017).
We further draw on Heise’s (1998) socio-ecological model of gender-based violence to iden-
tify salient risk and protective factors underlying violence. This model focuses on factors that
emerge across individual, relationship, community and society levels.
Methods
A description of the included interventions, theoretical frameworks for the interventions
and accompanying qualitative evaluations is presented in Table 1. The primary meth-
odological approaches used differ as they were evaluating different programmes and
populations, and this study was conducted as a secondary comparative analysis. In all
contexts, experienced qualitative interviewers external to the programme implementa-
tion team were hired and trained in qualitative research on violence and conducted the
interviews in local languages. The majority of interviews across the contexts were gen-
der-matched between interviewer and interviewee. Prior to work commencing on this
paper, data from all of the studies had been coded, analysed and published in country-
specific reports and papers, where further details of the interventions and methods can
be accessed (Addo-Lartey et al. 2019; Gibbs et al. 2017; Mastonshoeva et al. 2019; Stern
et al. 2018). This includes details and results of the accompanying quantitative evalu-
ation research conducted in all settings.
1702 E. STERN ET AL.
Table 1. Interventions and qualitative research.
The Rural Response System in Ghana
Context: The intervention was delivered in two districts of central Ghana, one inland and mostly rural where
participants lived in small villages and towns and were mainly farmers, and one coastal with small towns and
many households living from fishing.
Intervention: A six-person Community Action Team (COMBAT) per village was nominated by the community, trained
for 2 weeks with a refresher training after one year, and deployed per community. They worked through
community activities that raised awareness about the types and consequences of violence against women and
girls (VAWG), challenged inequitable gender attitudes, provided mediation and counselling for couples, engaged
leaders and state actors and strengthened linkages to response services. The intervention was implemented over
18 months.
Theoretical/conceptual framework: Through sensitisation, awareness creation, case management and referrals,
leading to pathways to improve attitudes to violence against women (VAW) at the individual and community
levels; and a reduction in VAW.
Implementation team: Gender Studies and Human Rights Documentation Centre.
Research methods: In-depth interviews (IDIs) were conducted with 20 adult women and 20 adult men who had
reported experience (women) or perpetration (men) of intimate partner violence in the baseline survey; IDIs
repeated at midline (12 months) and endline (24 months) with 54 men and 57 women in total. Scope: VAWG
knowledge and perceptions, experiences with the intervention, gender attitudes, stigma and violence for
survivors; changes in violence against women and gender attitudes, the role of and seeking help from COMBATs,
sustainability of the intervention. Focus group discussions (FGDs) were held with 20 men and 20 women from
the communities, following the same scope of inquiry at baseline, midline and endline. Groups were stratified by
gender and age (18–34 and 35–49 years). There were 2 FGDs with COMBATs at baseline, midline and endline
focusing on their perceptions of activities regarding awareness creation and support provided to survivors
of violence.
Indashyikirwa in Rwanda
Context: Indashyikirwa (Agents of Change) was implemented in seven districts across fourteen sectors in the
Eastern, Northern and Western provinces of Rwanda, in predominantly rural, widely dispersed communities.
Intervention: The intervention was delivered through a participatory curriculum with couples recruited from CARE’s
micro-finance village savings and loans associations (VSLAs) that spanned 21 sessions of 3 hours and was
delivered over 5 months. Community activism was then led by 500 men and women who attended the couples
curriculum and volunteered for a further 10 half days of training to equip them to implement activities, in a
programme that drew on SASA! established by Raising Voices. They facilitated 3–4 activities per month over 19
months. Safe space facilitators were trained for 10 days. The safe spaces were open 3 times a week for 22
months. They offered counselling, income-generating activities (IGAs), activism activities and supported
community members to access formal response services. Ten days of training and ongoing quarterly meetings
were provided for opinion leaders, who provided support for survivors and raised awareness over 30 months.
Theoretical/conceptual framework: The Indashyikirwa programme drew on the socio-ecological model to address
violence (Heise 1998), and thus purposefully included programme elements to address risk and protective factors
for violence at the individual, relationship and community levels.
Implementation team: CARE International, Rwanda Men’s Resource Centre (RWAMREC) and Rwanda Women’s
Network (RWN).
Research methods: IDIs were held with 15 male and female partners of couples at baseline, midline (7 months) and
endline (19 months) across 3 districts. Some were married and some cohabiting. Scope: Couples’ experiences of
conflict and intimate partner violence, communication skills and joint decision-making; whether and how
Indashyikirwa impacted their relationships. Twelve individuals who trained as community activists were
interviewed at 12 months and 30 months across 3 districts (2 men and 2 women per district). Scope: Impressions
of the activism training and support received, motivation to continue as activists, what they had been doing
recently as activists, and whether they faced any challenges. Opinion leaders were interviewed from across 3
districts: 9 at baseline, 6 at midline (9 months) and 9 at endline (12 months). Scope: Impressions of the training
and whether their involvement with the programme influenced their intimate partner violence prevention and
response actions. Three women’s safe space facilitators were interviewed at baseline (5 months), midline (18
months) and endline (30 months) across 3 districts. Scope: Motivations to be facilitators, impressions of training
and support received, perceived impact of the safe spaces. Women’s safe space attendees were interviewed
across 3 districts at 9 months (n¼ 6),18 months (n¼ 8) and 30 (n¼ 6) months into the study. Scope: Why they
visit the safe spaces and the difference the spaces make in their lives. Fifteen RWAMREC and RWN Facilitators
were interviewed across various districts at 7 months (n¼ 14) and 19 months (n¼ 12). Scope: Successes and
challenges engaging opinion leaders and supporting the safe spaces (RWN staff), and from training couples,
community activists and supporting community activism with trained couples (RWAMREC staff).
(continued)
CULTURE, HEALTH & SEXUALITY 1703
Table 1. Continued
Zindagii Shoista in Tajikistan
Context: Rural villages with high levels of poverty and limited economic opportunities. Many men migrate to Russia
in search of work, and women mostly live with their husband’s family.
Intervention: Zindagii Shoista (Living with Dignity) was implemented with up to four members of multi-
generational households and comprised 21 sessions (each 2.5 hours), over 15 months: 10 sessions focused on
building gender equity, respect and intrahousehold communication and reducing violence; and 11 sessions
worked with each family to develop a concept for an IGA, offer training in business skills and materials to
support starting an IGA (US$370/household). There was supervision and business support for each IGA.
Theoretical/conceptual framework: The intervention drew heavily on the Stepping Stones and Creating Futures
broad theoretical framework described below.
Implementation Team: International Alert, Cesvi and three Tajik NGO partners – ATO, Farodis and Zanoni Sharq.
Research methods: 21 IDIs (two – in one case three – men and three women in each village) and eight FGDs (one
per gender per village) were conducted with 9–13 participants. These were repeated at midline at 8 months
(n¼ 25), endline at 15 months (n¼ 25) and at 15 months post-intervention (n¼ 8). Scope: Prevalence of VAWG,
socio-economic situation, health and mental well-being; participants developed ‘everyday change indicators’ and
tracked these, allowing them to define and monitor issues they saw as pertinent. Two FGDs were conducted with
facilitators at each of the target districts involving four facilitators per district at the same time points.
Stepping Stones and Creating Futures in Durban, South Africa
Context: Urban informal settlements with exceedingly high levels of poverty, limited work opportunities and high
levels of violence and harmful alcohol use. Young people tended not to live with a partner, but on their own or
with friends.
Intervention: Stepping Stones and Creating Futures (SSCF) intervention was delivered in single-sex groups of
approximately 15–20 participants, with sessions lasting 3 hours, over approximately 3 months. Men and women
were recruited individually, not as couples. The 21 three-hour sessions included: 10 sessions focused on building
gender equity, respect and inter-personal communication and reducing violence; and 11 sessions from Creating
Futures, an intervention focused on getting and keeping work, saving and understanding the opportunities and
constraints for livelihoods.
Theoretical/conceptual framework: The intervention drew on theories of gender and power and how materiality
intersects with these. Processes of change were based on Freire’s ([1968] 2014) theory of dialogical
communication and critical thinking.
Implementation Team: Project Empower.
Research Methods: IDIs were conducted with 19 men at baseline, midline at 12 months (n¼ 5) and endline at
20–24 (n¼ 7) months, and 15 women were interviewed at baseline, midline at 12 months (n¼ 12) and endline
at 18 months (n¼ 13). They were living in two informal settlements participating in the programme. Scope:
Young people’s livelihoods, experiences of violence, intimate relationships, gender attitudes and whether and
how the intervention leads to changes in these issues. Interviews were supplemented by participant observation.
Women’s photovoice was conducted at baseline and 18 months with 8 and 6 women. Scope: Relationships,
reproductive decision-making, intimate partner violence, experiences and perceptions of power, livelihoods and
future aspirations.
Ethics
The projects received ethical approval from the South African Medical Research Council
(Ghana: EC031-9/2015; Rwanda: EC033-10/2015; South Africa: EC006-2/2015; Tajikistan:
EC012-5-2016). Additional national ethical approvals were obtained for studies in Ghana,
Rwanda and South Africa. In Tajikistan, given the absence of a functioning national review
board at the time of data collection, approval letters to certify compliance with research
ethics standards were obtained from the Tajik Academy of Dialogue and from local
authorities. Across all studies, written informed consent was obtained from participants,
and findings were anonymised. All studies included mechanisms for referring participants
either to professional counsellors or organisations to support survivors of violence.
Pseudonyms are used for quotations to protect the confidentiality of participants.
Joint data analysis
Qualitative data from all studies were audio-recorded, transcribed and translated ver-
batim into English. The data were then analysed thematically by the respective
1704 E. STERN ET AL.
investigative teams, using different thematic codes and areas of interest, although all
with the primary research question of assessing the impact of the local programme on
intimate partner violence. Respective teams, including the authors of this paper, coded
the data using a priori codes developed from the research topic guides. Further codes
that emerged during the process of thematic analysis were added to provide a rich,
detailed and holistic account of the findings.
For this paper, authors from Rwanda, South Africa and Tajikistan studies used the-
matically analysed midline and endline data (and for Tajikistan post-endline data) to
answer the following secondary questions: (1) How did participants make sense of
the impact of the intervention, and how did this understanding evolve throughout
the programme? (2) Which components of the intervention appeared to support
changes in intimate partner violence and why, and which did not, and with whom in
particular? and (3) What contextual factors facilitated or impeded the programmatic
changes and how? The first analytic question implies the use of an inductive
approach to access participants’ perspectives on pathways and processes of change.
The second and third analytic questions imply the use of a deductive approach with
respect to investigators’ perspectives on pathways of change. Original quotations
from the data set are included in investigators’ responses to these analytical ques-
tions. For this paper, the first author analysed the Ghana midline and endline data to
respond to these questions as the Ghana investigation team was unavailable for
this task.
The first author subsequently identified common patterns across the four studies. A
comparative case study approach guided the analysis and the presentation of the find-
ings, focused on similarities and differences around pathways and processes of change
to prevent and mitigate intimate partner violence.
Findings
Across the different studies, a range of similar pathways of change, potentially leading
to reductions in intimate partner violence, were identified. We discuss these using the
socio-ecological model’s structure.
Individual level pathways to change
Greater self-confidence
Participants in all settings reported improved self-confidence resulting from participa-
tion in the intervention, a significant individual-level change, which could be an
important protective factor against intimate partner violence. As Azin, a young woman
in Tajikistan, reflected at endline: ‘I became more brave and lively and have a vision
for my future’. Greater self-confidence was related to the pathway of intervention ele-
ments promoting empowerment. In South Africa, some women described how the
intervention gave them more power over their lives, especially to address the chal-
lenges they face: ‘SSCF [Stepping Stones Creating Futures] changed me because I am
now able to be independent, I am able to handle any challenges and accept that they
exist’ (Philani, midline, South Africa). Women also appreciated that the SSCF sessions
CULTURE, HEALTH & SEXUALITY 1705
reflected on goal-setting; for many it was the first time they had space to reflect on
their lives, dream and set goals: ‘I learned from the intervention that I must know
what I want in life, so I can succeed’ (Oyama, midline, South Africa). One of the under-
lying concepts of Indashyikirwa (adapted from SASA!) in Rwanda concerns the four
types of power: positive power (power to, power within, power with) and negative
power (power over). Most trained couples, women’s safe space facilitators and attend-
ees emphasised the value of the concept of ‘power within’ to recognise and use one’s
power positively: ‘Now I openly speak out and I use the power that I have in me and I
feel there is something that I can do to make my family developed. That is a very big
thing’ (Justine, midline, Rwanda).
Increased self-confidence for participants was also related to the perception that
they had gained greater recognition in their communities. The majority of activists
and safe space facilitators in Rwanda reported gaining community status for their
efforts, took pride in being recruited for this work and regularly wore Indashyikirwa
vests and badges to be identifiable. Similarly, several community members in Ghana
identified greater status and respect towards the Community Action Teams
(COMBATs). In Tajikistan, many women and men also reported greater respect and
acceptance in their communities and noted how this built their self-confidence. As
one young woman emphasised:
Prior to engagement in the intervention, I always felt bad and some form of guilt. I
thought I was the reason for the violence in our family. Before the intervention, no one
was even considering me as a person worth talking to. The neighbours were labelling our
family as a problematic family. Now I feel very happy, our family restored the respect of
the community. (Darya, post-endline, Tajikistan)
Shifts in attitudes towards violence and gender
Participants reported how the interventions supported them to change their attitudes
around the acceptability of violence and gender norms and roles. Participatory group-
based approaches encouraging sharing and critical reflection of experiences were
highly valued and enabled participants to collectively engage with new ideas and shift
harmful attitudes underlying intimate partner violence and gender inequality.
In Rwanda and Ghana, participants reported how the acceptability of violence was
reduced as they came to realise the negative impacts of violence. Emphasising the
value of peaceful relationships and communities also supported individuals to con-
demn violence:
Violence is not a good thing when you live in a peaceful community, you grow healthy,
when you have peace in your marital home, it helps you, it is not always about money.
Violence destroys your peace, especially we women when you experience violence, it can
affect your children, and your children will go astray, so we always pray to God to let
peace prevail. This is why we do not tolerate violence. (Focus Group with Women,
endline, Ghana)
A significant attitude shift in Tajikistan was the increasing acceptability within many
families for young women to work outside the home, which was encouraged through
the programme, and after families witnessed the financial benefits first-hand:
1706 E. STERN ET AL.
After the project sessions, the way my husband and mother-in-law relate to me has
changed. I found a job in a bathhouse as a cleaner. My husband and my mother-in-law
are not against my work before they used to be opposed to this idea. My mother-in-law
now supports me; whenever I go to work, she takes care of my children, helps with daily
chores. My husband supports me too. (Farhana, endline, Tajikistan)
Similarly, several men in Rwanda reported being increasingly supportive of women’s
economic activities after considering the household benefits and identifying this as
women’s rights.
In South Africa, many men described how they increasingly endorsed gender equal-
ity, particularly greater respect for women, which led to reduced use of intimate part-
ner violence and controlling behaviours against their intimate partners. Some women
in South Africa described resisting their partners’ controlling and violent behaviours
and shifting their expectations about gender relations to no longer tolerate such
behaviours: ‘I will not get back together with him [ex-partner], he is abusive and quick
to beat me. He wanted me to stay at home and cook and clean and do all the house
chores. I can’t live like that, not anymore’ (Buhle, PhotoVoice endline, South Africa).
While most women in South Africa remained in violent relationships, they shared
changing relationship expectations and reduced normalisation of intimate partner vio-
lence. One woman noted how she increasingly considered her relationship satisfaction
as a priority before considering the needs of her partner, which equipped her to leave
a violent relationship:
One of the things that helped me get out of that relationship was some of the things I
learned from the intervention. We learned that you must live life for yourself and that
your happiness matters more than the other persons’ and you must not stay with
someone who doesn’t make you happy. (Thandi, midline, South Africa)
However, limited changes in attitudes around some gender norms were also identi-
fied. In Tajikistan, beliefs around gendered domestic roles were difficult to change for
some participants, with childcare continuing to be seen as (young) women’s responsi-
bility. The continued salience of the norm of men as heads of households and primary
breadwinners was evident across settings. As one participant in Rwanda noted: ‘the
last decision is taken by a husband because he is a man and a man is the head of his
family … the head of the family is the one to take the final decision’ (Valentine, mid-
line, Rwanda). In South Africa, the continuation of norms around men’s provider roles
following SSCF could hinder women from engaging in income-generating activities.
Economic empowerment
In the three interventions that included livelihoods strengthening (South Africa,
Tajikistan and Rwanda), the impact of stronger livelihoods, combined with gender-
transformative sessions, reduced stress and built confidence and self-esteem. Most
young women in Tajikistan gained their first experience of involvement in economic
activities through the project, enabling them to earn and contribute to their family
budget. The combination of access to resources, an ability to provide and self-confi-
dence raised their self-esteem, status and respect from other family members.
Strengthened livelihoods meant less economic stress and related family conflict in
households, as one older man emphasised:
CULTURE, HEALTH & SEXUALITY 1707
The major benefit is that I could start making money for my family’s needs. My brother
and sister supplied food for my family. With the support of the project, I could take over
that responsibility. They are also happy that I could do it. There is still a long way to go
for the complete economic stability of our family, but I am happy I can at least cover
some basic needs. (Doro, post-endline, Tajikistan)
In South Africa, men and women appreciated the livelihood skills which enabled
them to improve their access to income-generating and education opportunities. For
men, the focus on livelihoods included developing plans to generate small incomes
and make progress towards longer-term goals. This aspect reportedly improved their
confidence, reduced their anger and frustration at their situation and in turn sup-
ported the movement towards reduced intimate partner violence. Several women
appreciated how SSCF enhanced their ability to look for and secure work and increase
their income: ‘The writing of the CV and letter, I learned how it’s done and how to
dress for an interview plus which points are important and what to expect from an
interview’ (Woman, midline, South Africa). In Rwanda, the stipend offered to each part-
ner for attending the couple’s curriculum session (2000 RWF, approximately US$2.5)
was identified as a motivating factor for participation, especially among men. In many
cases, couples used the micro-finance village savings and loans association (VSLA) sav-
ings and curriculum stipend towards a household investment, such as purchasing a
fridge, bicycle, roof or livestock. Many couples in Rwanda reported improved financial
security as the result of the programme, which reduced conflict, and couples made
more joint decisions and communicated more openly about resources:
When there is a conflict between a man and his wife, they cannot reach financial security,
they instead lose and consequently, their household remains in poverty. But when they
share ideas and give up quarrelling, there is peace at home, they work together and then
there is no more conflict. (Jean, endline, Rwanda)
Economic empowerment activities were critical to supporting change as all the pro-
grammes worked with communities from vulnerable socio-economic backgrounds.
Indeed, a few participants in Ghana, the only programme without an economic elem-
ent, highlighted the financial determinants and triggers of intimate partner violence
and suggested the intervention would have been strengthened by providing eco-
nomic empowerment activities.
Relationship-level pathways
Improved intimate relationship skills and quality
Across all settings, participants reported that the programme strengthened their rela-
tionship skills, particularly constructive communication and conflict resolution skills,
which in turn supported their ability to mitigate and prevent violence. Several women
in South Africa reported less frequent arguing and being more strategic about when
to communicate with their partner, including to avoid arguments if they or their part-
ner were drunk: ‘I learned that a person can be assertive and have a calm conversa-
tion with someone, without it turning into a fight’ (Nambusi, midline, South Africa).
Several men in South Africa reported the impact of learning conflict resolution and
1708 E. STERN ET AL.
communication skills for improving their relationships with others, including their part-
ners, and helping reduce their use of violence:
My girlfriend and I discuss things. I don’t just make decisions without communicating
with her, it’s a 50/50 agreement, we listen to each other, we are not in a perfect
relationship, we argue here and there, but there are ways we deal with those things. You
must understand your partner and not just hit her whenever you get into an argument.
(Thando, midline, South Africa)
Similarly, in Rwanda, women and men described improved relationship skills includ-
ing being able to identify and manage triggers of violence, asking for forgiveness, con-
structive communication and conflict resolution skills, leading to less violence and
conflict in relationships. The take-home activities from the couples’ curriculum, in
which couples were asked to practise a skill related to each session and reflect on this
at the beginning of the next session, helped participants apply new skills at home.
Couples completing the curriculum together said it helped to hold each other
accountable to changes in their relationships: ‘We have the same opinion about the
curriculum. We understand sessions the same, we even revise or remind the other in
case one of us goes wrong. This has helped us not to repeat the wrong’ (Marie, end-
line, Rwanda).
In Ghana, some female community members mentioned that, through awareness
and knowledge gained from the programme, they felt more equipped to control their
anger and impatience and had a better understanding of how some behaviours (e.g.
anger) could lead to intimate partner violence:
Some of us were impatient about certain things, we used to disrespect our husbands, but
we have been taught that exchanging words with your husband is not the best, those
who accepted the teachings have benefitted. (Focus Group with Women, endline, Ghana)
In Tajikistan, as well as reduced violence between partners, there was a reported
reduction in violence from in-laws, particularly reduced emotional abuse by mothers-
in-law against daughters-in-law, a common form of violence. This was connected to
improved relationships as a result of greater communication within families.
Improved relationship quality was also identified as an important pathway to
reduce intimate partner violence, particularly as a result of the interventions in
Rwanda and Tajikistan for working at the household level. In Tajikistan, the interven-
tion created spaces for the entire family to talk to each other openly, which improved
men’s understandings of women’s needs and everyday household burdens and helped
develop mutual respect. In Rwanda, several participants noted how completing the
curriculum together allowed for rare, positive time together, and fostered closeness
and intimacy.
Because we were in a secure and discrete place, everyone was free to say what he/she
thinks. So after that lesson, because everyone had said freely what was on his/her mind,
everyone went back to his/her home knowing what his/her partner likes and dislikes.
(Henriette, midline, Rwanda)
Despite positive change around respecting partners and building healthier relation-
ships, some women in Ghana and Rwanda misinterpreted the focus on respect to
mean it was their responsibility to prevent intimate partner violence by respecting
CULTURE, HEALTH & SEXUALITY 1709
and acquiescing to men so as not to provoke violence. This was related to the strong
norm of men as heads of households, as well as participants learning ways of commu-
nication and resolution skills to manage conflict:
I was disrespecting him, concerning the sexual intercourse I was not treating him as my
husband. Even when he told me: ‘come here and I tell you’ sometimes I would decide
just to leave him but now it has changed. I humble myself and I respect him. (Garuka,
midline, Rwanda)
I learned that as a woman, you have to respect your husband because he is the head of
the family, so you have to know how to talk to him even if you’re angry with him. I have
learnt how to deal with my temper because our inability to manage our anger well can
bring violence. (Focus Group with Women, endline, Ghana)
Gender-equitable roles and decision-making
Participants in each programme reported more gender-equitable relationships
between couples and in families, an important pathway to violence reduction. In
Tajikistan, many participants reported more gender-equitable household deci-
sion-making:
The project sessions on violence had a good impact on my husband. His attitude and
behaviour towards me and my daughters changed. Now he pays attention to family
problems. Now he asks for my opinion about family issues. (Gawhar, endline, Tajikistan)
In Rwanda and Ghana, a focus on families working together was central to the
changes in practices, with men reconsidering their role in the home, and engaging in
new behaviours, including care and domestic work, and couples making more equit-
able decisions. The concept of positive and negative types of power strongly reson-
ated with participants in Rwanda, and was said to underlie transformative changes,
including around inequitable gender roles:
The lesson that I see that has been the most useful and that we discuss so much at
home is the lesson about power. That lesson helped him because the problem of power
was about to destroy our marriage. He thought he was holding all the power.
(Immaculee, midline, Rwanda)
The programme in Ghana also emphasised the benefits of peaceful relationships
and couples working together, which similarly motivated changes in gender roles. For
instance, one participant related how a COMBAT member emphasised the relationship
benefits of men and women sharing domestic roles, which supported her husband to
participate in domestic work after being teased by his friends:
My husband stopped helping me with house chores at some point because his friends
were teasing him any time they see him helping me to wash. When the COMBATs came
to speak to us, they made it clear there is nothing wrong when a man helps his wife with
house chores. He said when we do it, we help each other and that will result in a
peaceful marriage. (Adwoa, endline, Ghana)
Yet, across all programmes many participants shared the challenges of transforming
power dynamics and gender roles in their relationships, with men continuing to have
the final say in decision-making, and women being predominantly responsible for
domestic and care work. In Rwanda, although women reported greater decision-
1710 E. STERN ET AL.
making power in relationships as a result of the programme, several men and women
shared how men increasingly helped their wives with domestic and care work, but on
men’s terms. Although domestic care continued to be identified as women’s responsi-
bility in Tajikistan, young women stated that men increasingly helped them with this,
indicative of how individual attitudes and behaviours and roles in relationships are not
always aligned.
Community-level pathways
Group-based participatory approaches
Across all the interventions, the participatory nature of the intervention facilitated
processes of change, as participants could share and critically reflect on key issues and
built a strong rapport with others. This approach, which enabled reflection and self-
expression, contrasted with the didactic and authoritarian education system many par-
ticipants in South Africa had experienced: ‘I was able to raise my opinion because we
all allowed each other to speak … I was comfortable and felt free if I wanted to
speak, I would speak, plus there were no wrong answers, every answer was right’
(Luphumlo, midline, South Africa). Similarly, in Rwanda, most participants were highly
appreciative of the participatory approach of the curriculum, supporting a safe space
in which to share and reflect on difficult/taboo issues without feeling judged.
Groups also provided an important space to build relationships with others. Despite
living in dense informal settlements in South Africa, many women and men reported
feelings of isolation and valued the interactions provided by the groups alongside
having something more meaningful to do with their time: ‘During the intervention,
we had a break from everyday life. It’s better to do something, not just sit at home all
day, not talking and interacting with anyone’ (Nolwazi, endline, South Africa). The
intervention in South Africa offered a rare opportunity for men to share painful experi-
ences with others and in turn develop emotionally supportive relationships:
This brother, the way he was struggling and the situation he was in, he showed me that
if you have nothing in life it doesn’t mean that it’s over. You have to try and struggle by
all means until you are successful. That’s the story that stuck with me, and other stuff like
you must share your problems with other people, you have to speak in order to get help
in the end. (Langa, midline, South Africa)
In Rwanda, couples commented on the strong rapport they built with other couples
by the end of the curriculum and valued how they could draw on each other for sup-
port. This group rapport was especially important to bolster the confidence and cap-
acity of the participants who transitioned to become community activists. A similar
process was seen in Tajikistan where the participatory curriculum enabled greater
communication between age hierarchies to emerge and challenge inequitable gender
dynamics. Facilitators in Tajikistan noted at baseline that younger women tended to
criticise dominant gender norms and mother-in-law/daughter-in-law relationships, but
only when speaking in a smaller group without older women present. By midline and
especially endline, facilitators observed this had shifted, and in the larger group dis-
cussions younger women expressed their views and questioned dominant gender
CULTURE, HEALTH & SEXUALITY 1711
norms. Older women at times encouraged younger participants to speak and were
more attentive and respectful of their comments.
Yet difficult group dynamics, particularly in South Africa and Tajikistan, sometimes
impacted intervention effectiveness. While many women in SSCF reported they found
the friendships and groups supportive, others reported they did not feel safe or sup-
ported in the groups. Group tensions included participants arguing or gossiping about
what had occurred in the session, or being laughed at when they spoke in sessions: ‘It
was when we were sharing the true stories about our lives, and when I tried to speak,
Ndoni began laughing and I felt uncomfortable and I told them that I will not speak
anymore’ (Woman, midline, South Africa). Although the intervention in Tajikistan sepa-
rated groups according to age and gender hierarchies to promote sharing and dia-
logue, other community dynamics were present that could hinder such openness:
In our village the success of the project is challenging. See, I am local, and even if we live
in the same village, we are from different avlods [extended families/clans]. I would never
share my family problems in front of people from this other avlod. (Feda, post-
endline, Tajikistan).
In Rwanda, ensuring equal engagement by men and women was initially challeng-
ing, and men often dominated the curriculum discussions, but through careful facilita-
tion and greater group rapport this issue reduced over time.
Enabling environments
A key component that supported change in the community was how programmes
worked at a community level, engaging leadership and working to connect families to
important forms of support. In Tajikistan, improved community relations as a result of
the programme were widely reported through the post-intervention data collection.
Older women, in particular, mentioned an increase in mutual support and help for
resolving issues, such as accessing drinking water, irrigation and other infrastructure.
For younger women, an indication of better community relations was reduced social
control through gossip, more supportive attitudes towards women’s employment out-
side the household and increased mobility.
In Ghana and Rwanda, several participants reported the value of the programmes
in sharing information on property rights and inheritance laws for women to support
more equitable access for women and children to property:
Before COMBAT, what was happening in this community was that when a man dies, his
extended family members will claim all the man’s properties leaving the widow and the
children with nothing. But since COMBAT started these things have stopped. (Kisi,
endline, Ghana)
The strong relationships that developed between local leaders, activists and safe
space facilitators through the Indashyikirwa programme (including through quarterly
coordination meetings) enabled activists in Rwanda to access existing community
forums for activism. This allowed for wider reach and diffusion of the messages and
was said to enhance the credibility of the activists. In Ghana, activists were similarly
supported by local leadership and as a result had access to a variety of community
occasions (e.g. funerals, weddings) to allow diffusion of messages.
1712 E. STERN ET AL.
Support for the survivors of intimate partner violence in Ghana and Rwanda was
critical for programme success. Activism emphasised that survivors should not be
blamed for experiencing violence, but rather should experience support from their
communities:
When there is violence, the community intervenes which is different from before. They no
longer say ‘it is her fault, she is the one who provoked that violence that she is suffering.’
They have understood that even if she may be wrong, it should not make her a victim of
violence. (Valentine, endline, Rwanda)
These efforts were important in changing conceptualisations of violence and foster-
ing individual and community responsibility to intervene. The women’s safe spaces
provided in Rwanda were highly appreciated and actively used. In Ghana, COMBATs
were identified by several men and women as uniquely able to resolve domestic dis-
putes and provide supportive responses to intimate partner violence survivors:
‘COMBATs are the only group in this community to teach us marital issues. Since they
are trained to handle marital issues, I know whatever the case may be, they can help
solve it’ (Kofi, endline, Ghana).
In Rwanda and Ghana, participants stressed the value of referral to social, health or
justice services, community leaders or women’s safe spaces in Rwanda, to ensure lon-
ger-term and varied solutions as well as immediate responses. In addition, it was
important for activists (and safe space facilitators in Rwanda) to accompany individuals
to seek services, to reduce potential intimidation and provide needed support: ‘A
woman can go to court with some of the COMBAT members. Because there will be a
need for witnesses that is why it will be the best to go with the COMBAT so they
could get the truth out’ (Focus Group with Women, endline, Ghana). However, a few
men in Ghana reported being uncomfortable seeking help from COMBATs, for fear of
being reported or prosecuted. Several participants lamented how men were not as
actively engaged in the programme because they were too busy or uninterested, or
perceived the programme as favouring women:
The men complain to us that COMBAT takes sides with the women. I am suggesting the
next time, issues from men should also be addressed in the intervention. On the logo it is
written ‘violence against women and girls or children’, and that means they are not
involved. They feel they are not favoured. (Focus Group with Women, endline, Ghana)
Discussion
Across varying contexts and programmes, similar pathways of change to reduce intim-
ate partner violence were identified through this comparative analysis. At the individ-
ual level, participants, particularly women, identified how through participation in
interventions they gained greater self-esteem and confidence, reduced their tolerance
of abuse and inequalities in relationships and better prioritised their own relationship
needs. At the relationship level, participants across the studies reported shifts in harm-
ful gender norms and roles, including men and women more equally sharing house-
hold and provider roles, and more equitable decision-making. Yet the limits of the
programmes’ abilities to effect fundamental transformation around gender norms
within programmatic timeframes were also evident.
CULTURE, HEALTH & SEXUALITY 1713
Other papers from these data sets have discussed the difficulty of shifting men’s
headship roles and patriarchal power in Rwanda (Stern, Heise and McLean 2018) and
South Africa (Gibbs et al. 2020). An earlier evaluation of Stepping Stones with adoles-
cents in South Africa found that women showed greater assertiveness and some
agency in HIV risk reduction, yet the majority did not challenge their male partners or
the cultural norms of conservative femininities (Jewkes, Wood and Duvvury 2010). In
the analyses presented here, some female participants reported respecting and acqui-
escing to men’s headship role as a strategy to prevent violence, and more widely
there was a fundamental inability to adequately challenge patriarchal power. This
affirms the importance of regularly and meaningfully targeting inequitable gender
norms and power relations, and for individual-level interventions to be complemented
by structural initiatives to challenge broader patriarchal norms (Willan et al. 2019).
A critical pathway to reduced intimate partner violence was the integration of
economic empowerment activities into programmes, which had multiple benefits for
participants and generated structural-level change. Economic components helped
reduce economic stress, a critical driver of intimate partner violence (Buller et al.
2018). In addition, women’s engagement with livelihoods enabled them to be seen
as contributing financially to the household, earning them greater respect and
authority and increasing their sense of self-worth. In Tajikistan and Rwanda, the
involvement of women’s family members supported women to become involved in
the economic empowerment components, and reduced risk of this fuelling conflict
or intimate partner violence. For men, improved livelihoods also supported their self-
esteem and confidence, especially given the prioritisation of men’s provider roles in
all settings.
Another pathway to reducing intimate partner violence was the emphasis on
healthier, more equitable relationships, by understanding the causes and consequen-
ces of violence and applying relationship skills to mitigate it. This supports other data
suggesting that poor communication and handling of partner conflict are contributing
factors to intimate partner violence (Conroy et al. 2016). Relationship skills learned
within programmes included identifying triggers of violence and more assertive and
constructive approaches to communication and conflict resolution. Applying these
skills allowed participants to experience and reflect on the benefits of greater cooper-
ation, communication and non-violence among intimate partners, or within families. It
was particularly effective to strengthen relationship skills within households (families
in Tajikistan and couples in Rwanda), enabling participants to have a shared under-
standing of and hold each other accountable to these skills. Indeed, the literature sug-
gests that when both partners of couples receive information about conflict resolution
tools, they are more likely to feel invested in applying these to negotiate conflicts
(Todahl et al. 2012). The development of skills further supported participants’ self-con-
fidence, together with the programme elements that promoted empowerment, and
greater community status of participants. Emphasising the benefits of equitable, non-
violent relationships also supported motivation and active engagement of participants,
especially men. This aligns with other literature suggesting that men need the space
to consider how gender inequalities can be harmful to both women and men and the
benefits of gender equality (Clowes 2013).
1714 E. STERN ET AL.
The participatory nature of the programmes was important for the development of
bridging and bonding social capital (Campbell and MacPhail 2002), which were add-
itional pathways to change. The groups offered rare spaces for participants to reflect
on harmful behaviours and develop alternative norms, supporting the literature that
such approaches can provide platforms for change through reflexivity and conscious-
ness raising (Campbell and MacPhail 2002). Group-based approaches additionally
allowed for powerful rapport and the emergence of a supportive environment for
change in ideas and practices (Stith et al. 2004). However, in our analysis challenges
were also identified to build group rapport and trust, which speaks to the importance
of facilitators being supported and trained to secure this, and to carefully monitor the
dynamics of group-based interventions.
The analysis also highlighted the importance of bridging social capital between
activists and local leaders, especially to ensure an enabling environment for activism
approaches. In Tajikistan, an unexpected consequence of the programme was greater
social cohesion, which created an enabling environment for programmatic changes.
Providing support to female survivors of intimate partner violence in Rwanda and
Ghana was an identified pathway of change for more empowering responses and
shifting community conceptions of violence. This speaks to the importance of working
at the intimate partner violence prevention and response continuum, especially when
applying activism approaches to foster community-level changes. Men were identified
as more difficult to engage in community-level activities in Rwanda and Ghana, includ-
ing to shift rigidly held attitudes and beliefs around gender and violence, and to be
encouraged to seek support to reduce their perpetration of violence, which speaks to
the importance of programmes carefully considering how community-level efforts can
support and engage men.
Limitations
Like all research, this analysis has its limitations. There may be social desirability bias
with participants wanting to report favourably on interventions they clearly valued.
Each study attempted to mitigate this by using researchers external to the programme
and emphasising the confidentiality of answers. The fact that this secondary analysis
found similar domains of change, and openness from participants around programme
limitations or challenges, enhances the validity of the findings. Moreover, observa-
tional data, and data from staff, where available, helped triangulate the perspectives
of participants.
An additional limitation of this study is that the first author, who was external to
the Ghana research team – conducted the secondary analysis of the thematically ana-
lysed data from Ghana. However, the findings were interpreted and validated by the
Ghanaian research team, including two co-authors of this paper.
We also recognise the potential investigator biases and limitations of secondary
analysis. However, investigators were asked to share original data as part of their sec-
ondary analysis and report on barriers and enablers to change, as well as strengths
and limitations of changes, which helped mitigate such biases.
CULTURE, HEALTH & SEXUALITY 1715
Conclusion
This qualitative comparative case study provides important insights into programmatic
pathways of change. Tracing how participants interacted with intervention ideas and
opportunities, as they took place in different contexts through varying approaches,
can generate understanding of the design and implementation elements pertinent to
bringing about change in intimate partner violence.
Acknowledgements
The views expressed and information contained are not necessarily those of, or endorsed, by
DFID, which accepts no responsibility for such views and/or information, or any reliance placed
on them.
Disclosure statement
We wish to confirm that there are no known conflicts of interest associated with this
publication.
Funding
This paper is an output from the DFID UK What Works to Prevent Violence Against Women and
Girls Programme funded by UK Aid from the UK Department for International Development
(DFID) with funds managed by the South African Medical Research Council.
ORCID
Erin Stern http://orcid.org/0000-0001-8800-0176
Samantha Willan http://orcid.org/0000-0001-8629-887X
Andrew Gibbs http://orcid.org/0000-0003-2812-5377
Henri Myrttinen http://orcid.org/0000-0002-8566-867X
Rachel Jewkes http://orcid.org/0000-0002-4330-6267
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